I hereby authorize:
(Agency) ___________________________________________________________________
(Address)___________________________________________________________________
to exchange information
about my child ___________________________ Date of Birth ______________
with (Clinician) ____________________________________________________________
(Address)___________________________________________________________________.
Please exchange the following types of information (check all that you approve):
_____ questionnaires
_____ academic records
_____ medical records
_____ mental health records
_____ developmental testing/assessments
_____ other (specify)
I understand that:
this authorization is aimed at assisting my child's doctor in helping my child.
this authorization is voluntary.
my child's treatment will not change if I do not agree to this.
the only risk is loss of confidentiality. I also understand that the computer system
being used by the teacher to answer questions about my child is secure.
my child's records are protected as confidential under Federal law.
I may revoke this consent at any time except to the extent that action has been
taken on it (e.g., already communicated).
this consent automatically expires in one year, if my child changes doctor or if my
child is no longer cared for by this agency.
that I may copy this form and that I may request a copy of the information
provided.
